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Journal of Elder Abuse & Neglect

ISSN: 0894-6566 (Print) 1540-4129 (Online) Journal homepage: http://www.tandfonline.com/loi/wean20

The Lichtenberg Financial Decision Screening Scale(LFDSS): A new tool for assessing financial decisionmaking and preventing financial exploitation

Peter A. Lichtenberg PhD, ABPP, Lisa Ficker PhD, Analise Rahman-FilipiakMA, Ron Tatro BA, Cynthia Farrell MSW, James J. Speir MSW, Sanford J. MallJD, Patrick Simasko JD, Howard H. Collens JD & John Daniel Jackman Jr., MD

To cite this article: Peter A. Lichtenberg PhD, ABPP, Lisa Ficker PhD, Analise Rahman-FilipiakMA, Ron Tatro BA, Cynthia Farrell MSW, James J. Speir MSW, Sanford J. Mall JD, Patrick SimaskoJD, Howard H. Collens JD & John Daniel Jackman Jr., MD (2016) The Lichtenberg FinancialDecision Screening Scale (LFDSS): A new tool for assessing financial decision making andpreventing financial exploitation, Journal of Elder Abuse & Neglect, 28:3, 134-151, DOI:10.1080/08946566.2016.1168333

To link to this article: http://dx.doi.org/10.1080/08946566.2016.1168333

Accepted author version posted online: 24Mar 2016.Published online: 24 Mar 2016.

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The Lichtenberg Financial Decision Screening Scale(LFDSS): A new tool for assessing financial decision makingand preventing financial exploitationPeter A. Lichtenberg, PhD, ABPPa,b, Lisa Ficker, PhDa, Analise Rahman-Filipiak, MAa,b,Ron Tatro, BAc, Cynthia Farrell, MSWd, James J. Speir, MSWe, Sanford J. Mall, JDf,Patrick Simasko, JDg, Howard H. Collens, JDh, and John Daniel Jackman Jr., MDi

aInstitute of Gerontology, Wayne State University, Detroit, Michigan, USA; bDepartment of Psychology,Wayne State University, Detroit, Michigan, USA; cCenter for Elder Rights Advocacy, Elder Law ofMichigan, Lansing, Michigan, USA; dAging and Adult Services, Adult Protective Services, State ofMichigan Department of Health and Human Services, Lansing, Michigan, USA; eSpeir Financial Services,Southfield, Michigan, USA; fMall, Malisow and Cooney, PC, Farmington Hills, Michigan, USA; gSimaskoand Simasko Law Firm, Mount Clemens, Michigan, USA; hGalloway and Collens, PLLC, HuntingtonWoods, Michigan, USA; iPrivate Practice Cardiologist (Ret.), Tyler, Texas, USA

ABSTRACTOne of the challenges in preventing the financial exploitationof older adults is that neither criminal justice nor noncriminaljustice professionals are equipped to detect capacity deficits.Because decision-making capacity is a cornerstone assessmentin cases of financial exploitation, effective instruments formeasuring this capacity are essential. We introduce a newscreening scale for financial decision making that can be admi-nistered to older adults. To explore the scale’s implementationand assess construct validity, we conducted a pilot study of 29older adults seen by APS (Adult Protective Services) workersand 79 seen by other professionals. Case examples areincluded.

KEYWORDSFinancial decision making;financial exploitation;financial judgment;protective services

An 82-year-old man with undiagnosed vascular dementia gets caught up in the“grandparent scam,” in which someone purporting to be a grandchild asks formoney to get themselves out of legal trouble overseas, and over the course of 1week he wires money from his bank account five times and loses $100,000. An84-year-old man with mild to moderate Alzheimer’s disease can no longermanage his money or even shop at the local grocery store, but when taken to abank he signs a notarized reverse mortgage and loses $240,000 to his handyman—who, unbeknownst to the man’s family, has secretly befriended him over theprevious 6 months. And a 79-year-old man with undiagnosed dementia losesmore than $2 million over a 14-month-period to his late wife’s former caregiver.In this case, Adult Protective Services (APS) visited him four times and took hisword each time that he knew what he was doing—without taking any steps to

CONTACT Peter A. Lichtenberg PhD, ABPP, p.lichtenberg@wayne.edu Institute of Gerontology andDepartment of Psychology, Wayne State University, 87 E. Ferry Street, Detroit, MI 48202, USA.

JOURNAL OF ELDER ABUSE & NEGLECT2016, VOL. 28, NO. 3, 134–151http://dx.doi.org/10.1080/08946566.2016.1168333

© 2016 Taylor & Francis

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assess his capacity for financial decision making. As these types of cases becomeincreasingly common, the criminal justice system and financial services industryattempt to better detect financial incapacity and exploitation.

Did these older individuals understand their decisions and appreciate theirimpact? It appears that they did not. But more importantly, how would abanker or APS worker in the above scenarios know without having any wayto assess the older adult’s capacity? Until now, no assessment measurescapable of being administered in the field by APS and other professionalshave been available.

To address this critical gap, we have created a screening scale designed toassess decisional ability at the point at which an older adult is making asignificant financial decision. This brief screen can be used by financialprofessionals and others (e.g., an APS worker called to investigate potentialexploitation or a banker being asked to transfer large amounts of cashoverseas). We will introduce the conceptual bases for our scale and provideempirical evidence for the scale’s criterion-related and construct validity.

Before introducing our 10-item scale, however, it is important to place itwithin the context of current measurement approaches to financial exploita-tion and to describe the full-length, 77-item Lichtenberg Financial DecisionRating Scale (Lichtenberg, Stoltman, Ficker, Iris, & Mast, 2015) from whichthe screening questions were derived. In addition, we provide an overview ofthe cognitive factors, and particularly cognitive decline, associated withfinancial decision making.

The approach we use is novel in the field of financial exploitation, in that weexamine the phenomenon by focusing on the older adult’s decision-makingprocess as it applies to a single financial decision the individual is considering(as opposed to a hypothetical scenario, which has traditionally been used toassess financial competency). It is not, however, without precedent. Dong(2014) argues that accurate assessment of financial capacity—and financialdecision-making capacity in particular—is the cornerstone assessment inmany cases of financial exploitation. We acknowledge that this focus ondecisional capacity does not cover all forms of exploitation (e.g., identity orother theft), but in many cases of financial exploitation, examination of anolder adult’s financial decision-making process presents a unique opportunityfor intervention and, ideally, prevention.

The dramatically increasing number of older adults in America under-scores the fact that the cognitively impaired population will close to tripleover the next 35 years (Hebert, Scherr, Bienias, Bennett, & Evans, 2003). Thecollision between an increasingly older population with high prevalence ofcognitive impairment (Plassman et al., 2008) and frailty (Bandeen-Rocheet al., 2015) and those seeking to exploit them financially is rapidly increasing(Lichtenberg, Sugarman, Paulson, Ficker, & Rahman-Filipiak, in press).Pillemer, Connolly, Breckman, Spreng, and Lachs (2015) summarize data

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that indicate that the presence of dementia or cognitive impairment isassociated with increased prevalence of elder abuse, and Stiegel (2012) hasfound that financial capacity and financial exploitation are connected.Specifically, older adults’ vulnerability is twofold: (a) the potential loss offinancial skills and financial judgment, and (b) the inability to detect, andtherefore prevent, financial exploitation. Money lost by older adults due tofinancial exploitation is rarely recovered, and if large amounts of money areinvolved, the older adult has few means to recover from the loss. Preventingfinancial exploitation, therefore, is a critical need.

Literature Review

Financial exploitation and the measurement of decision-making capacity

The most comprehensive measure to date for assessing financial exploitationis a self-report instrument, the Older Adult Financial Exploitation Measure(OAFEM; Conrad et al., 2011; Conrad, Iris, Ridings, Langley, & Wilber,2010). Carefully constructed and later validated against cases substantiatedby APS workers, Conrad and colleagues (2010, 2011) define the financialexploitation of older adults as the illegal or improper use of an older adult’sfunds or property for another person’s profit or advantage. They propose sixdomains of financial exploitation: (a) theft and scams, (b) abuse of trust, (c)financial entitlement, (d) coercion, (e) signs of possible financial abuse, and(f) difficulty managing money.

The OAFEM is a yes/no questionnaire designed to assess whether theolder adult has been victimized by any of the forms of financial exploitationnamed above. For example, question #47 asks whether the older adult hasbeen the victim of a scam that involved giving to a bogus charity. These andother questions are excellent for identifying the areas to investigate, andwith a nondefensive and reflective older adult, the answers are likely to bevaluable for substantiating past or ongoing abuse. Because the scale isdesigned to measure how much exploitation has taken place in the past,however, it does not assess current performance-based financial judgmentor decision-making capacity, such as understanding the consequences of apending financial decision. As a result, older adults who are not aware thatthey are being victimized, due to emotional manipulation and/or cognitiveimpairment, may not give an accurate self-report.

These deficits in financial decision-making abilities are often the hiddenelement in financial exploitation cases. Other researchers have measuredaspects of elders’ financial decision-making ability through assessment offinancial literacy and hypothetical scenarios (Boyle et al., 2012; James,Boyle, Bennett, & Bennett, 2012). Financial literacy is interpreted as theability to perform simple calculations (e.g., add up purchases and interest

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rates), and knowledge of financial concepts such as stocks, bonds, andcompound interest, which the authors acknowledge may not apply to seniorswith limited education (Boyle et al., 2012). Hypothetical financial situationsare designed to simulate (a) the resources and documents used in real-worldfinancial settings (e.g., checkbook management) and (b) making an invest-ment decision based on a scenario (James et al., 2012; Marson et al., 2000).The above tools are useful when conducting a comprehensive assessment butwould not be practical when the older adult is weighing an actual financialdecision. In contrast, the brief screen we propose combines evaluation forpotential financial exploitation and assessment of decisional abilities, and it isintended for use in the context of a significant real-life financial decision.

Marson (2001) conceives of financial capacity as relating to three things:(a) specific financial abilities, (b) broad domains of financial activity, and (c)overall financial capacity. In his 2001 study, for example, financial capacitywas strongly linked to stages of Alzheimer’s disease. In subsequent studies,Marson and colleagues have employed the eight-domain Financial CapacityInstrument (FCI; see Martin et al., 2008 as an example), including assess-ments of basic monetary skills, financial knowledge, cash transactions, check-book management, bank-statement management, financial judgment, billpayment, and knowledge of personal assets and estate arrangements.

One significant weakness of the FCI is that it uses neutral or hypotheticalstimuli (e.g., “How could you be sure the price of a car is fair?”). Yet validand reliable tools are essential if we are to adequately assess financialdecision-making abilities specific to the individual at risk, especially regaringsentinel financial transactions, which are defined as transactions that mayresult in significant losses or harmful consequences.

Cognitive decline and financial decision making

Several recent studies have investigated financial decision making in couplesin which one person shows cognitive decline. Study findings demonstrate thevalue of an assessment tool that offers protection where needed, but alsosupports autonomy whenever possible. Over a 10-year period, Hsu and Willis(2013) examined financial management in couples in which one party hadcognitive deficits, and found that cognitive impairment, rather than cognitivechange, was related to greater financial difficulties. Indeed, difficulties withmoney often preceded the turning over of financial control from the cogni-tively impaired spouse to the unimpaired spouse, which was usually relatedto pending decisions about self-directed financial investments. Even so, 33%of financial respondents in the study continued to be the primary financialdecision maker, despite having cognitive scores in the dementia range. Thesedata underscore the heterogeneity in how couples cope when the primaryfinancial decision maker becomes cognitively impaired, and demonstrate that

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is not unusual for older adults with cognitive impairment to be placed in adecision-making role, even when other options are available.

Boyle and colleagues (2012) examined how cognitive abilities beforedementia onset predicted financial decision making 5 years later, andfound (using hypothetical mutual fund options) that more rapid cognitivedecline led to poorer decision-making abilities, even in participants with mildcognitive impairment. These results are consistent with Marson et al.’s (2009)research on financial capacity. Marson (2001) (also see Marson et al., 2009)argues that the impact of age-related dementia (e.g., Alzheimer’s disease) onfinancial capacity is one of the biggest challenges to financial autonomy.

Although cognitive functioning is an important predictor of decisionalcapacity, other factors may also influence these abilities. Boyle (2013) pointsout that financial decision-making capacity differs from executional capacity(e.g., the ability to manipulate money, pay bills, and understand and main-tain an accurate checkbook). In nearly 25% of the couples studied, the personwith dementia retained decisional capacity, even in the absence of execu-tional capacity. Boyle’s findings of individual differences underscore theinherent ethical tensions. First and foremost, one must always be aware ofthe fundamental tension between autonomy (self-determination) and protec-tion (beneficence; Moberg & Kniele, 2006; Moye & Marson, 2007). It can betempting to use generalized findings—such as the fact that older adults are atrisk for financial scams and theft—and apply them to an individual case, nomatter the circumstances, to protect the older adult. This would be a mistake,because autonomy remains a strong need across the adult lifespan, andmental health professions have a duty to protect it whenever possible.

Conceptual underpinnings for a new screening instrument

The development of our instrument was guided by two conceptualframeworks: (a) person-centeredness and (b) decisional abilities. Theseframeworks affirm the importance of assessing the older adult’s under-standing of the actual financial decision in question, with the require-ment that the older adult communicate four important elements of hisor her decision: choice, understanding, appreciation, and reasoning.

A person-centered approach to financial decision making

In working with older adults who suffer from neurocognitive disorders, theperson-centered approach seeks to support autonomy by building on theindividual’s strengths and honoring his or her values, choices, and prefer-ences (Fazio, 2013). Some of the underlying assumptions (Mast, 2011) arethat (a) people are more than the sum of their cognitive abilities, (b) tradi-tional approaches overemphasize deficits and underemphasize strengths, and

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(3) it is important to understand the person’s subjective experience, particu-larly in relation to his or her positive and negative reactions to others’behavior. Whitlatch (2013), who emphasizes the importance of personswith neurocognitive impairment continuing to have choice, found thateven people scoring well into the impaired range on the Mini Mental StateExamination (MMSE) can provide valid and reliable responses. Mast (2011)describes a new approach to assessment of persons with neurocognitiveimpairment, the Whole Person Dementia Assessment, which seeks to inte-grate person-centered principles with standardized assessment techniques.

Decisional abilities framework

Our second conceptual approach is based on Appelbaum and Grisso’s (1988)decisional abilities framework. In 1988, Appelbaum and Grisso examined thelegal standards used by states to determine incapacity and identified theabilities or intellectual factors necessary to make informed decisions: choice,understanding, appreciation, and reasoning. These have since been reiteratedas fundamental aspects of decisional abilities (American Bar Association[ABA] Commission on Law and Aging & American PsychologicalAssociation [APA], 2008). Indeed, the ABA/APA’s Assessing DiminishedCapacity in Older Adults: A Handbook for Attorneys (2008) urges attorneysto assess the older adult’s underlying decision-making abilities, wheneverdiminished financial judgment is suspected.

According to the decisional abilities framework, an older adult must be ableto communicate choice, understanding, appreciation, and reasoning aroundthe choice. An individual must be able to communicate his or her choice andunderstand the nature of the proposed decision and its risks and benefits.Appreciation is the ability to grasp the situation and its potential consequences—which may affect not only the older adult, but family members and others aswell. Appelbaum and Grisso (1988) contend that the most common causes ofimpaired appreciation are lack of awareness of deficits and/or delusions ordistortions. Reasoning includes the ability to compare options—for instance,treatment alternatives in medical decision making—and provide a rationale forthe decision or explain the communicated choice.

We aimed to build on the conceptual model of decision-making abilitiesdescribed by Appelbaum and Grisso (1988) and incorporate the WholePerson Dementia Assessment approach by using both person-centered prin-ciples and standardized assessment methods. Person-centered principlesallow for the fact that even in the context of dementia or other mental orfunctional impairments, the individual may still possess important areas ofreserve or strength, such as financial judgment. The value of standardizationis that it allows a domain to be assessed across time and across practitioners,with the assurance that the same areas will be evaluated.

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However, only when an assessment is rooted in a specific sentinel financialtransaction or decision can a third party render an opinion on the presenceor absence of financial exploitation, since financial decision-making capacityin high-risk older adults is rarely completely present or completely absent(Dong, 2014). Our 10-item screening scale, which is designed to assesscapacity to make a real-life financial decision or transaction—rather thanone in a hypothetical vignette—is an outgrowth of our work on a longer,more comprehensive financial decision-making scale (see below).

Development of the Financial Decision-Making Rating Scale

The comprehensive scale will be described briefly and tied to our creation ofthe shorter screening scale. Until now, medical and mental health profes-sionals have not had a scale that assesses financial judgment by evaluatingboth the context in which a decision is being made and the person’s under-lying decision-making abilities. To close this gap, we created the 77-itemLichtenberg Financial Decision-making Rating Scale (LFDRS; Lichtenberget al., 2015). Our first article on the LFDRS described the methods used forits creation and initial reliability (Lichtenberg et al., 2015).

The LFDRS consists of four subscales: Financial Situational Awareness,Psychological Vulnerability, Susceptibility to Undue Influence, andIntellectual Factors (i.e., decisional-ability factors). Videotaped LFDRS inter-views were conducted with five older adults. Following Marson et al.’s (2009)methods, interrater reliability was established across 10 independent raters byhaving multiple raters view the videotapes and score the LFDRS. In oursecond article (Lichtenberg, Ficker, & Rahman-Filipiak, 2016), we presentedpreliminary criterion validity results for the LFDRS. Due to its length,however, the LFDRS is impractical for use by criminal justice, financial, orsocial service professionals.

Tradeoffs between comprehensive and screening scale

There is always a tension between doing comprehensive assessments andusing screening scales. The benefits of screening scales are threefold(MacNeill & Lichtenberg, 1999); (a) brevity; (b) sensitivity, and (c)level of training required. Precisely because screening scales are brief,they can be used across more settings by more professionals. A secondadvantage of screening scales is that although they are brief, they canhave substantial validity. Finally, the level of training required to use ascreening scale is much less than comprehensive measures. In the fieldof cognitive testing, for example, a comprehensive cognitive evaluationtakes a minimum of 90 to 120 minutes and requires a high level oftraining in the administration of psychometric testing. A screening scale

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such as the Mini Mental State Exam (Folstein, 1975), for example, takes5 to 10 minutes to administer. The level of training required to admin-ister the MMSE is much lower than that of comprehensive cognitivetesting. The MMSE, like all screening tests, has significant limitationstoo, with higher rates of false positives and/or false negatives than acomprehensive assessment (see Mast et al., 2001). In the present situa-tion the LFDRS requires a high level of training, advanced interviewingand rating techniques, and an ability to integrate the findings from allsubscales into a clinical judgment. Only highly trained professionals arelikely to use it, thus limiting its impact. Our screening scale provides avehicle where the strength of our approach can be utilized by criminaljustice and noncriminal justice professionals alike.

Conceptual underpinnings of our screening scale

The fundamental frameworks of person centeredness and decisional abil-ities were retained in the screening scale. Person centeredness is adheredto in the screening scale in two important ways; (a) the scale directlyassesses the older person’s experience, and (b) the questions are directlyrelated to the financial decision at hand and not an artificial one that theymay not relate to. Even more fundamentally, there is a deep respect forthe individual, a core concept of person centeredness, in any approachthat elicits the individual’s perspectives through questions that require theindividual to communicate informed decision making and does notmerely seek assent. The inclusion of items related to susceptibility toundue influence are in keeping with the respect of the individual andthe individual’s agency.

Decisional abilities framework, the most often cited aspects of decision-makingcapacity across a broad array of decisions, is highlighted in the screening scale.Questions related to choice, appreciation, understanding, and rationale were allincluded in the screening scale. To enable significantly more practitioners to elicitdecisional abilities of older adults, we created a significantly shorter instrumentthat focuses on the decision-making abilities subscale, which assesses intellectualfactors. These are the functional abilities required for financial decision-makingcapacity, and include an older adult’s ability to (a) express a choice, (b) commu-nicate the rationale for the choice, (c) demonstrate understanding of the choice,and (d) communicate appreciation of the relevant factors involved. We also choseseveral items from the Susceptibility to Undue Influence subscale. The result wasthe 10-item Lichtenberg Financial DecisionMaking Screening Scale (LFDSS). Thefirst empirical article to examine LFDRS and LFDSS criterion-related validity wasrecently published (Lichtenberg et al., 2016), and we will now discuss the results ofthat study in terms of the screening scale.

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Criterion-related validity

We examined criterion-related validity in 69 older African Americans(Lichtenberg et al., 2016) and found that the LFDSS risk score was significantlyrelated to both theMMSE (r = –.26; p < .05) and the moneymanagement subscaleof the Independent Living Scale (ILS), which is a performance-based measure ofexecutional skills and financial knowledge (r = –.20; p < .05). The LFDSS risk scorewas increased for those with poorer cognition, poorer financial executional skills,and lower financial knowledge. Other evidence for criterion validity was that theLFDSS risk score differentiated between those who had been financially exploitedin the past 18 months and those who had not (t = 3.83; p < .001), whereas the ILSmoney management subscale did not (t = 1.5; p > .05). Finally, the LFDSS riskscore differentiated those with decisional capacity from those who lacked decisio-nal capacity (t = 3.1; p < .05). Taken together, these initial results provided positivecriterion-related validity of the LFDSS. Nevertheless, future work will need toderive criterion validity from administration of the LFDSS alone.

Purpose of the study

Using this sample to investigate several aspects of construct validity, we soughtto examine the normative data to determine whether age or education effectswere present. We also evaluated the scale’s ability to differentiate (a) those whohad been financially exploited from those who had not, and (b) those who haddecisional ability deficits from those who did not. To accomplish these aims,we collected data from two separate sources, APS workers and other profes-sionals who work with elders (see Methods section for details).

Three hypotheses related to the LFDSS were generated:

● Hypothesis 1: Age, gender, and education will be unrelated to the LFDSSrisk score in older adults who are not being financially exploited and forwhom there are no concerns about financial decision-making capacity.This is a critical determination, because identifying whether scale inter-pretation requires correction based on age, gender, or education isessential for accurate scale development.

● Hypothesis 2: The LFDSS risk score will be significantly higher for olderadults whose financial decision-making capacity has been rated as ques-tionable (some or major concerns) by non-APS professionals than forolder adults whose financial decision-making capacity has been rated asintact (no concerns).

● Hypothesis 3: The LFDSS risk score will be significantly higher for olderadults whose financial exploitation has been substantiated by APS pro-fessionals than for older adults whose financial exploitation has not beensubstantiated.

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Methods

Participants

Adults age 59 or older were eligible for the study if they were making, or hadmade in the previous 6 months, a significant financial decision (or group ofrelated decisions, e.g., multiple gifts to the same person). In addition, theolder adult had to be evaluated by one of the participating professionals andagree to administration of the LFDSS. There was no overlap of participantsbetween APS and non-APS cases.

Front-line professionals from APS and a variety of other fields assessed108 participants for financial capacity and/or financial exploitation andadministered the LFDSS to each. Seventy-nine cases were evaluated bynon-APS professionals across a 12-month period: 55 by one of six elderlaw attorneys, 10 by one financial planner, 3 by one sheriff, and 11 by twophysicians. Twenty-nine cases were seen by APS workers across a 6-monthperiod and eight Michigan counties. The only inclusion criteria were that afinancial decision was present, and that the adult was over the age of 60 andwilling to participate. Scales were administered to consecutive older adultsages 60 and over when the inclusion criteria were met. In all cases, partici-pants’ age, education, and gender were collected, but personal or identifyinginformation was not (Table 1). Mean age was 75 years, mean educationallevel was more than 13 years, and 58% were female. Because the data wereanonymous, the Wayne State University Institutional Review Board issued aconcurrence of exemption. Although written informed consent was notrequired, the individuals being assessed received an information sheet thatincluded the elements of a consent form.

Table 1. Demographic percentages for elders screened at APS (substantiated cases vs. not) andby professionals (decision making concerns vs. ok).

APS* cases (n = 29)financial exploitation vs. not

Professional** cases (n = 79)decision-making concerns vs. ok

Total sample(n = 108)

Demographicvalues

Casesubstantiated

Caseunsubstantiated

Decisionalconcerns

No decisionalconcerns (Mean or %)

Age (mean/SD) 71.1 (10.3) 74.6 (14.8) 75.5 (10.1) 80.8 (9.8) 75.3 (10.7)Gender (%)Female 61.1 38.9 58.3 61.2 58.3Male 38.9 63.6 41.7 38.8 41.7

Education(mean/SD)Years ofeducation

12.4 (2.2) 12.8 (2.0) 14.2 (2.9) 14.2 (3.0) 13.8 (2.9)

APS* = Adult Protective Services; Professionals ** = Lawyers, financial planners, MD/medical professionals,law enforcement.

Note: No significant differences in age, gender, or education within the APS cases (substantiated vs. not) orprofessional cases (decision-making concerns vs. OK).

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Procedures

The APS and other professionals, all of whom were volunteers, were trainedas follows. First, the person received in-person or webinar-based training thataddressed cognition, cognitive decline, and dementia in older adults; finan-cial exploitation; financial capacity and financial decision making; and thelinkages between financial decision making and financial exploitation andspecific applications of the LFDSS. Second, videos of four administrations ofthe LFDSS, as well as a video that gave an overview of the instrument’sconceptual approach, were provided. Lastly, the LFDSS creator contactedeach professional within 2 weeks to answer any questions about how toadminister the scale and use its rating system.

Measures

Demographic measuresAge, gender, and education were collected by self-report. It is important toknow whether LFDSS scores are significantly related to any of these variables,because this could bias the scale if it is highly related to demographicmeasures.

Lichtenberg Financial Decision-Making Screening Scale (LFDSS)The LFDSS contains 10 items—7 from the LFDRS (2015) Intellectual Factorssubscale and three from the LFDRS Susceptibility to Undue Influence sub-scale. Two scores were calculated for the non-APS professional. First, theadministering professional assigned an overall decision-making score thatranged from 0 (Major concerns) to 2 (No concerns). This is the same type ofscoring for which Lichtenberg et al. (2015) demonstrated interrater reliabilityand criterion-related validity (Lichtenberg et al., 2016). Second, an overallrisk score was assigned using 5 of the 10 items. For these 5 items, theliterature supports the use of an ordinal risk score. For example, if thefinancial decision poses high risk or significant changes to previously estab-lished bequests, a higher risk score would be assigned than in cases ofminimal financial risk or no changes to bequests. The other five LFDSSitems are descriptive and neutral—for instance, there is no way of determin-ing whether a new will is riskier than a new investment or gift. For each ofthe five items, however, the highest risk score is assigned when the admin-istrator rates the older adult’s response as inaccurate or the older adult doesnot know the correct answer. Two scores were also derived for APS profes-sionals: (a) whether financial exploitation was substantiated or unsubstan-tiated and (b) an overall risk score.

Specific information on scoring is available from the corresponding author.

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AdministrationThe LFDSS is a structured, multiple-choice interview intended to be admi-nistered in a standardized fashion. In introducing the LFDSS to the olderadult, the administrator is instructed to read a one-sentence explanationaloud to the older adult:

“I am going to ask you a set of questions to better understand the financialtransaction/decision you are making or have already made. Please answerthese as best you can and feel free to elaborate on any of your answers.”

Questions are to be read aloud as they are written. If the older adultresponds before the choices are offered and a rating can be made, theinterviewer can make the rating without reading all of the choices. If neces-sary, however, the interviewer should read all of them aloud and ask theperson to choose one.

The interviewer is encouraged to allow the older adult to expand onany answers and to write down what the person says. The interviewer canask the older adult to elaborate, or the person may do this spontaneously.The interviewer is also encouraged to ask follow-up questions and recordthe person’s answers.

Scoring each itemThe LFDSS is a rating scale, and therefore the interviewer’s judgment iscritical. Scoring involves two steps and should be done as follows:

1.On each item, the older adult’s response should be recorded by circlingthe person’s answer(s).

2.On each item, the interviewer should place an X next to the answer thatthe interviewer believes is most nearly correct. For example, if the responsegiven is not accurate or it appears the older adult does not know the answer,the interviewer should place an X in the box next to “Don’t know/inaccurateresponse.”

Data Analysis

To test Hypothesis 1, age, gender, and education level were correlated withthe LFDSS risk scores using Pearson correlations (and with gender point-biserial correlations) to determine whether those individuals who were notbeing exploited and for whom there were no decision-making concerns hadLFDSS risk scores that were significantly related to the person’s age, gender,or education. Fisher’s exact tests were then used to determine whether theLFDSS risk score differentiated those who were rated as having financialdecision-making capacity concerns from those who were not (Hypothesis 2).Fisher’s exact tests were then used to determine whether the LFDSS risk scoredifferentiated those who were being financially exploited, as determined byAPS, from who were not (Hypothesis 3).

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Results

Of the 29 APS cases, 18 (62%) were judged to be substantiated for financialexploitation and 11 to be unsubstantiated. Of the 79 non-APS professionalcases, 10 (12%) were judged to have deficits in decision-making capacity and69 to have full financial decision-making capacity. A summary of the groups’characteristics can be found in Table 1.

The correlational results used to test Hypothesis 1 are shown in Table 2.The analyses used to test Hypotheses 2 and 3 are shown in Table 3; as can beseen, LFDSS risk scores for individuals for whom APS workers had sub-stantiated financial exploitation were compared to those for whom there wasno APS substantiation. These groups differed significantly in LFDSS riskscores (t = 3.06; p < .005). Additionally, cases in which non-APS profes-sionals raised concerns about decision-making abilities were compared tocases in which they had no concerns, and LFDSS risk scores differed sig-nificantly between groups (t = −4.41; p < .01). Taken together, LFDSS riskscores significantly differentiated older adults who were rated as (a) beingexploited from those who were not and (b) raising concerns about financialdecision-making deficits from those who were not. These results supportboth hypotheses 2 and 3, and demonstrate aspects of construct validity of theLFDSS. Criminal-justice cases involving older adults with substantiatedfinancial exploitation demonstrated the same financial decision-making inca-pacity as did cases of older adults with financial decision-making incapacitywho, with a non-APS professional, were attempting to complete a significantfinancial transaction. Therefore, financial decision-making deficits were a keycomponent of exploitation in one set of cases and incapacity in the other set.

Table 2. Correlations for the normative group (no financial exploitation and no decision makingconcerns; n = 78).

Age Education LFDSS total risk

1.Gender (1 = female; 2 = male) −.06 .15 −.072. Age −.30** .29**3. Education −.074. LFDSS total risk score(range 5–30)

**p ≤ .01

Table 3. Independent samples t-tests for the LFDSS total risk score for current financial decision.M (SD) t df p

LFDSS total risk score APS case substantiated 14.50 (6.3) 3.06 26 .005APS case not substantiated 8.20 (2.0)

LFDSS total risk score Professional case:Decisional concerns

17.42 (6.8) −4.41 77 .001

Professional case:No decisional concerns

8.63 (2.1)

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Significant differences were found on most answers to the LFDSSscreen based on the context (APS vs. non-APS professional). The mostcommon type of financial decision for the non-APS cases was estateplanning (wills and decisions about beneficiaries and powers of attor-ney), and, for APS cases, giving a gift(s)—although more than one third(37.9%) of APS cases could not accurately communicate the type offinancial decision they were attempting to make. In the majority ofnon-APS cases (83.5%), the financial decision was rated as posing noor low risk, while this was the case in only one third of the APS cases.Almost one half (41.4%) of APS cases acknowledged that the decisionwould impact them negatively or put them in debt, while none of thenon-APS cases rated the impact as negative (although 10% of theseanswers were judged to be inaccurate). More than twice the number ofAPS cases rated family members as being negatively affected by thecurrent decision (41.4% vs. 19% for non-APS cases). Approximatelyone half of the APS cases (48.3%) had not discussed the financialdecision with anyone, while a similar proportion of non-APS cases(49.4%) had discussed the decision in depth.

Case example #1

A 68-year-old woman reported to her social worker that she was consideringpurchasing a house for her unemployed grandson. The grandmother lived on afixed income and had very little wealth or cash resources. When the LFDSSwas administered, she correctly stated the choice she wanted to make (buy ahouse for her grandson) and said that although it was his idea, she had comearound to liking it. She also stated that this would pose no financial risk for herand that she would benefit the most. She failed to recognize, however, that ifher grandson failed to make the mortgage payments, she would be heldresponsible—thereby demonstrating lack of understanding—and because hewas unemployed, she would be putting herself at great financial risk, therebydemonstrating lack of appreciation. The social worker concluded that thewoman had major decisional-ability deficits and helped her refrain frombuying the house. In this case, the woman wanted to give her grandsonsomething that would show her love and support for him. When she washelped to understand the transaction’s financial risk and its potential conse-quences, however, she was open to being dissuaded.

Case example #2

An older couple visited their attorney with the desire to change theirindividual wills, dividing their monies to their grandchildren and not theirchildren, as they believed their children had accumulated significant wealth

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already. Although the couple both appeared to agree with the plan, theattorney was worried that the 93-year-old husband had significant memoryproblems that might interfere with his testamentary capacity. The attorneyhad the wife leave the room and administered the screening scale to thehusband. The husband described his choice as leaving his money to hischildren equally (the current will) and did not independently recall wantingto change his will. The attorney changed the will for the wife but left thehusband’s will alone and did not change it.

Discussion

Most notably, our results strongly support Dong’s (2014) assertion thatdecision-making capacity is the cornerstone assessment in cases offinancial exploitation. Even so, most financial-exploitation scales (e.g.,Conrad et al., 2010) do not include measurement of the older adult’sfinancial decision-making abilities. Instead, financial-capacity scales pri-marily focus on executional skills and are based on hypothetical scenar-ios (e.g., Marson, 2001). This renders such instruments impractical foruse by front-line professionals, because the measures fail to assesswhether the older adult’s decision-making skills for a specific transactionare also compromised. As a result, there is a dearth of assessmentinstruments that can be used by APS workers or other professionalswho assist older adults in making significant financial decisions. Ourstudy provides evidence for the first financial decision-making screeningscale that, in addition to being efficient, is person-centered (i.e., basedon the actual decision being considered) and operationalizes Appelbaumand Grisso’s (1988) model for decision-making abilities into a multiple-choice rating scale.

Preliminary evidence is ample for the construct validity of the LFDSS. Therisk score operates in a similar fashion for those who have been financiallyexploited and those who have financial decision-making deficits. It alsodiffers significantly for (a) those who have been exploited financially com-pared to those who have not and (b) those whose financial transaction wasnot carried out due to the professional’s concerns about capacity comparedto those with no capacity concerns.

The question of what are the best practices when a positive screen (i.e.,major concerns about a decision) occurs has yet to be answered. It would bea best practice to follow up a positive screen with a referral to a professionalwho could perform a more comprehensive decision-making capacity assess-ment. It is rare that this occurs in actual practice; both the lack of profes-sionals trained in this type of geriatric capacity assessment and the lack offunds to pay them play a major role in this scarcity. Still, it is important forthe professionals using the screening scale to understand that like any

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screening scale, this is a gross measure, a guide and certainly not a definitiveassessment. Nevertheless, a screening measure such as this can help improvethe decision-making processes already faced by professionals working witholder adults.

It must be noted that our results are preliminary; a larger sample sizewill be required to perform factors analysis and item analyses on thescale. In addition, the number of APS cases was relatively small. Notest–retest reliability was determined in this study, nor were cognitivedata collected. Nevertheless, the study yields two important findings.First, the LFDSS can be easily taught to professionals, and second, itcan differentiate cases in which concerns about decision-making capacityare present from those in which they are not. We anticipate that theLFDSS will prove to be useful for a wide range of professionals whoeither investigate financial exploitation or, when decisional capacity isimpaired, seek to prevent it.

Funding

Funding for this project was provided in part by the following grants: the National Institute ofJustice MU-CX-0001, National Institutes of Health P30 AG015281, Michigan Center forUrban African American Aging Research, Retirement Research Foundation, AmericanHouse Foundation, and Robert and Martha Sachs.

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